Avoiding surgical mistakes (Proceedings)

Avoiding surgical mistakes begins BEFORE surgery with appropriate workup of each case on an individual basis. Work-up in most cases consists of collection of a data base that defines the disease processes being considered in the differential diagnoses.

Data Base

CBC, Chemistries, and Urinalysis are part of almost all work-ups.

Other tests may be "routine" depending upon the signalment, disease process, and patient.

-FeLV and FIV tests

-T4 levels in geriatric cats

-Echocardiography in geriatric cats, Dobermans (CVI)

Consider cross-matches and the need for blood products

Thoracic Radiographs for metastasis

Ultrsound examination of the abdomen may help stage disease or detect occult disease present concurrently

CT or MRI studies are excellent in some cases in characterizing the extent of disease processes, i.e.- Invasiveness of neoplastic disease

Surgical Preparation

A surgical plan should be formulated for each case. Alternatives to the primary surgical plan should be considered should the primary plan not go as planned. The plan should include the specific goal of surgery. Is it for diagnostic or therapeutic purposes or both? If there is doubt about what surgery is intended for a plan can be better formulated when a diagnosis is KNOWN. For example, often times we will pursue a "tissue diagnosis" prior to definitive surgery when possible. Incisional or needle (tru-cut biopsy) will permit amore rational plan to be constructed prior which may include surgery, medical management, radiation therapy, etc.

In considering the surgical plan, select the right operation for the right disease!

-A dog with end-stage ear disease will NOT benefit from a lateral ear canal resection, a Total Ear Canal Ablation is most appropriate in this case

- A dog with hip dysplasia is unlikely to benefit from surgery for it's hips if the real problem is an ACL tear or the dog has Degenerative Myelopathy

Consider the need for blood products such as whole blood, packed red blood cells, and /or plasma. What are the indications for specific blood products?

Whole Blood

Packed Red Cells

Plasma

When considering oncologic surgery the specific disease/diagnosis and the biology of that disease should be considered when constructing the surgical plan.

-The first surgery is the BEST surgery for attempting complete resection

of malignant tumors.

i.e- Fibrosarcoma in the cat

-The first 3 rules of oncology are Biopsy, Biopsy, Biopsy! (Withrow)

Consider the need for specific instrumentation, its availability, and its sterility PRIOR to surgery.

-Suction and electrocautrery are mandatory in the modern surgical suite

-Balfor Retractors for abdominal surgery provide an "extra pair of hands"

-"Lone- Star" retractor is a VERY useful and versatile retractor in avariety of operations

Consider the availability of postoperative 24 hour intensice care (ICU) and the possible need for that care postoperatively

Consider how the patient will be fed postoperatively, Does the animal need a PEG tube or esophagostomy tube?

Consider the plan and timing for analgesic/antibiotic administration intra and post op. Will intraoperative cultures be appropriate or needed? What type os surgery is being performed?

Clean

Clean Contaminated

Contaminated

Dirty

Consider your abilities and experience and interest/desire as a surgeon BEFORE beginning surgery. We would like to avoid "Peek and shriek surgeries" when possible.

-Some surgeries can be learned from the textbook (Salivary Mucocele) while some surgeries require experience scrubbing in with an experienced surgeon or concentrated cadaver and possibly live dog work in a Continuing Education setting.

Technically difficult common surgical procedures or procedures that need CE training:

-Thoracic Surgery/Thoracic Wall Resections

-Intervertebral disc surgery

-Hepatic lobectomy

-Biliary diversion procedures such as cholecystoduodenostomy

-Portosystemic shunts

-Total ear Canal Ablation (TECA)

Surgery (The Operation)

Practicing the principles of modern surgery as perfectly as possible is an excellent starting point in avoiding intraoperative mistakes

-Asepsis

-Atraumatic tissue handling (Don't crush tissue), USE instruments correctly

-Hemostasis

-Exposure

Adequate exposure through a generous incision makes the surgeon much more comfortable, confident, and accurate in performing surgery.

Consider your surgical plan and be as complete as possible.

-Exploratory Celiotomy

Initially ignore the obvious if possible and perform a complete and systematic exploration. Exceptions to this rule are active hemorrhage or leaking abdominal viscus which should be attended to immediately.

-Be open to deviate from your surgical plan if necessary but consider the consequences of deviation.

i.e.- Performing biopsies of some organs is performed with low morbidity. Performing a liver lobectomy or right adrenalectomy of a tumor that has invaded the vena cava may change the operation completely especially if you have not discussed this with the owners previously.

Be cautious about over-interpretation of intraoperative findings especially in regard to "on the table euthanasia".

-Some liver and splenic masses are benign (Nodular hyperplasia) thus biopsy may be required to differentiate benign from malignant lesions

-If in doubt about any tissue finding/appearance biopsy is almost always appropriate

Use the correct suture and size on the correct needle for specific purposes.

-Size 2/0 suture is NOT appropriate for every use in every operation on every animal

Consider the appropriateness of closure (or NOT) of specific skin wounds

Consider the use of ACTIVE drains for deep wounds versus Passive (Penrose) drains for superficial wounds.

-If you consider use of a drain, the wound probably needs it!

Submit ALL excised tissue for a histologic diagnosis.

-A histologic diagnosis is NOT optional or upto the owner in our practice, the cost is included as part of the whole procedure.

-Consider asking the pathologist to specifically examine the margins of excised tissue, some do this routinely, others do not.

Post-Surgery

Consider and pursue the cause of complications early in the postop period.

If the animal does nhot respond as expected postop rethink the diagnosis or consider other complicating factors

If the histologic diagnois does not fit the clinical impression consider asking for a 2nd pathology opinion on tissue.